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P-Q-LSC_Y_FORMS . & ENDORSEMENTS <br />The following are the policy forms and endorsements that apply to your current professional Ilability insurance policy <br />COMMON POLICY FORMS& ENDORSEMENTS <br />FORM # <br />QE$CRIPTION <br />G-1 21500-1) <br />Common Policy Conditions <br />G -121503-C <br />Workplace Liability Form <br />G421501-01 <br />Occurrence Policy Form - California <br />G -145184-A <br />Policyholder Notice - OFAC Compliance Notice <br />G -147292-A <br />Policyholder Notice - Silica, Mold & Asbestos Disclosure <br />GSL15563 <br />Information Privacy Coverage Endorsement HIPAA Fines, Penalties & Notification Costs <br />GSL15564 <br />Sexual Misconduct Sublimits of Liability Professional Liability & Sexual Misconduct Exclusion <br />GSL15565 <br />Healthcare Providers Professional Liability Assault Coverage <br />GSL17101 <br />Exclusion of Specified Activities Reuse of Parenteral Devices and Supplies <br />GSLI3424 <br />Services to Animals <br />CNA80051 <br />Amended Definition of Personal Injury Endorsement <br />CNA80052 <br />Distribution or Recording of Material or Information in Violation of Law Exclusion Endorsement <br />G -123846-D04 <br />California Cancellation and Non -Renewal <br />ONA81753 <br />Coverage & Cap on Losses from Certified Acts Terrorism <br />CNA81758 <br />Notice - Offer of Terrorism Coverage & Disclosure of Premium <br />CNA82011 <br />Related Claims Endorsement <br />CNA79575 <br />Exclusion of Cosmetic Procedures <br />PLEASE REFER TO YOURCERTIFICATE OF INSURANCE FOR THE POLICY FORMS & ENDORSEMENTS SPECIFIC <br />TO YOUR STATE AND YOUR POLICY PERIOD. <br />For NJ residents: The PLIGA surcharge shown on the Certificate of Insurance is the NJ Property & Liability Insurance <br />Guaranty Association, <br />For KY residents: The Surcharge shown on the Certificate of Insurance Is the KY Firefighters and Law Enforcement <br />Foundation Program Fund and the KY LGPT is the KY Local Government Premium Tax which <br />includes charges at a municipality andlor county level. <br />For WV residents: The surcharge shown on the Certificate of Insurance is the WV Premium Surcharge, <br />For FL residents: The FIGA Assessment shown on the Certificate of Insurance is the FL Insurance Guaranty Association <br />- 2012 Regular Assessment. <br />Form#: G-141241-8 (03/2010) Named Insured:Felice R Hernandez <br />Master Policy#:188711433 Policy#:0619799393 <br />